Henry Blackburn

Quotes

R: Why did you become a member of the CVD Epidemiology Council?

H: That’s not a particularly applicable question for me, because I was involved with epidemiological activities in AHA before we were a Council. As you’ve seen, I’ve written a history of the Council.

R: Right, there was a committee first and then you really had to struggle to become a Council.

H: That’s right. I wrote that history with Fred Epstein published in Circulation in 1995 in considerable detail. There was a Committee on Epidemiological Studies in another Council of American Heart. And in that committee there was a sub-committee on Criteria and Methods. We still have such a committee in the Council. Fred Epstein was the first chairman of that subcommittee and I worked with him, being very much involved at that time, late 1950s, with CVD survey methods and ECG coding for our Minnesota studies. I also began in the early ‘60s writing a WHO Manual with Geoffrey Rose, “Cardiovascular Survey Methods,” and so that’s how I got involved with Fred Epstein and the National AHA. Locally I was involved in starting a Minnesota Heart Association Cardiac Rehab Unit and other Minnesota Affiliate offices. That was all before the AHA Council on Epidemiology was formalized in 1964.

Actually a series of annual scientific meetings epidemiology and preventive researches, such as we’re still having in the Council, started in 1960 in Chicago, when we weren’t yet a Council. They were privately funded and led by Oglesby Paul who, with the statistician Felix Moore and others, was working to get our group full Council status in AHA. We were a small group then and very much involved in those meetings and in the early days of formal CVD epidemiological studies. The AHA archives in Dallas and our CVD History Archive here in Minnesota have the early programs and attendees of these meetings. A few dozens of us were grandfathered in as fellows of the Council when we finally became one in 1964. This is all documented in an early history of the council by AHA staff person, Len Cook, and by Epstein and my article in Circulation. 

R: What was it like to be the Chair?

H: When I became Chair in the fall of ’71 it was during a very interesting period in the history of cardiovascular epidemiology. Many results on risk predictors were in from the first round of cohort studies; Minnesota, Framingham,Albany, Los Angeles and others started in the late 40s and early ‘50s. The Risk Factor Paradigm was pretty well established by then and beginning to be applied in trials and in practice. We were all activating strongly for clinical trials of modifying these risk factors, singly and all together. There had been a pilot study called the National Diet-Heart Pilot Study that reported on feasibility of one such trial in 1968 and recommended a definitive National Diet-Heart Trial for prevention of coronary disease. That expert recommendation terrified officials at NIH that it would take up all their staff and funds for the next decade to do this study. So while they postponed the decision, for 3 years, little happened in national research policy for CVD prevention. In the book we are writing on the early History of Cardiovascular Disease Epidemiology, we called that “The Pause.” There was a hiatus where no real national or international policy existed on where we would go in cardiovascular disease epidemiology and prevention research or program. All were waiting for a formal decision on whether to do a diet-heart trial.

So it was at that time I became Council chairman. I had been on Sabbatical for a year in Geneva working with WHO and at the Geneva Cantonal hospital doing the first early ambulation in cardiac rehab study there. They were keeping infarct patients in bed six weeks when I got there, and so we did a randomized trial on early mobilization. It was fun, and worked out well, both medically and economically (for the frugal Swiss).

At any rate, the activists in our AHA group, Fred Epstein, Jerry Stamler, Ancel Keys, Richard Remington, Henry Taylor, myself, along with Europeans such as Geoffrey Rose, Martti Karvonen, Gösta Tibblin and others, began to get active to justify and encourage progress. During that frustrating period, between ’68 and ’71 when little was happening as far as national policy on CVD prevention research, we met, created reports, wrote essays, lobbied with NIH, and put together an international conference, the Makarska Conference on Mass Prevention Trials, where the needs were outlined for single and multi-factor trials and for continued cohort studies, all intended to put pressure on NIH and WHO. NIH was interested in action but frantic not to get buried in a diet trial and also not happy to be ”scooped” by trials beginning in Sweden, and by European multi-center trials started by WHO, etc.

Then, after these national and international deliberations, at the fall scientific meeting of AHA in 1971, finally, Ted Cooper, the head of the U.S. National Heart Institute, having achieved resolution among his staff and the U.S. scientific community, proposed in the Lyman Duff Lecture, a broad new U.S. policy on CVD prevention. The NHLI Task Force on Atherosclerosis Report of 1971, the Joint Commission Report of 1970 from many organizations including the AHA, and the Makarska Conference, all made strong recommendations for definitive trials of CVD prevention. So in our treatment of CVD history we date 1972 as the beginning of the “modern era” of cardiovascular disease epidemiology and prevention, where there was a national policy. At the same time, WHO was calling meetings of international experts on trials, and in 1971 organized the multi-risk factor trial in industry that Geoffrey Rose of London headed. Others were moving, too. Thus, there was a strong forward motion right at the time that I became head of the AHA Council. AHA was right in the middle of it and it was a very good time to be in our Council in respect to initiatives and funding and collegial planning and effort.

Also, some of the same activists had participated on the faculty of the first three annual 10-Day Seminars, the international seminars started at Makarska in 1968 as a major effort of the International Society of Cardiology Council on Epidemiology. The second was held in Pioppi, Italy where Ancel Keys had a home, and the third in Sweden. So, with the experience of three international seminars, one of the main agenda items of my service on the American Heart Council was to start a North American 10-Day Seminar. Its organization took place in summer 1973 here in Minneapolis, with the first seminar held, near the home of Nemat Borhani at Lake Tahoe, California, after he became chair in 1974. This was in response to a strongly perceived need for a U.S. and other regional seminars as our field was growing. More and more younger clinicians and investigators were interested and needed the orientation that the seminars provided in such stimulating academic environs. The international seminars recently held their 40th anniversary and the Tahoe Seminar its 35th, indicating the successful fulfillment of an international training need.

All in all, it was a very exciting period, the 1960s and early 1970s, perhaps a Golden Era of cardiovascular epidemiology. Things were then ready to move forward in research, practice, and policy, and we saw both national and international policies and programs put in place along with adequate support.

R: Great. This almost answers the next question that I thought of. What were the greatest achievements that occurred during your term as Council chair, and I think you’ve already very nicely outlined their beginnings.

H: Well, it wasn’t only our Council, but a lot of things happened at that time. And what our Council was responsible for was being activist at all levels throughout the scientific community in encouraging new policy on prevention. Also we helped that policy to be established in WHO and in American Heart and at NIH and all concerned were happy about that. What actually got started in ’72, included the WHO Multiple Risk Factor (MRF) Trial in Industry, The Gothenburg MRF Trial, the U.S. Hypertension Detection and Follow-up Program, the U.S. Multiple Risk Factor Trial, and the U.S. Lipid Research Centers that became an international outreach involving the LRC Prevalence Study and the Primary Prevention Trial with cholestyramine. So, many, many things started right about that time, in policy, new researches, and in training and academic programs in CVD epidemiology.

R: What then were the biggest achievements in CVD over the past 60 years?

H: These contributions included establishing epidemiology as an accepted scientific strategy equal to clinical and laboratory research, at least academically and administratively if not in funding. Scientifically and administratively epidemiology is now a fully equal partner with the other traditional methodologies. Just establishing that equity was very important. Our Council can take some of that credit, along with its pioneers, and particularly with the 1950s director of our National Heart Institute, James Watt. He was also centrally involved in WHO’s CVD initiatives that were crucial for the international developments in our field.

Obviously, the carefully collected evidence on CVD risk factors and establishment of the risk factor paradigm and use of risk factor scores as multivariate analysis and computing became possible, brought the primary early contributions of CVD epidemiology. The generation of preventive trials lowering risk factor levels came next in line, giving the evidential base for preventive practice and public health promotion in the population. We can’t really claim that we as a discipline or as a Council were responsible in any direct way for the decline in coronary death rates of the latter 20th century, but epidemiological evidence played a part in it as did improved cardiac care. We know that from surveillance studies indicating an improvement in both out-of-hospital sudden deaths and in case fatality rates.

The other larger contribution is that we as a discipline and Council have encouraged population thinking and a population strategy of prevention that embraces the medical strategy and is presumably not in competition with it. The population strategy of prevention, the training and research, and the community activity in health promotion for diet, activity, and anti-hypertension program, and anti-tobacco legislation, all go along with that larger contribution. Not only did epidemiology provide the base of evidence for public health policy and prevention but gave the real promise and potential of prevention. This, of course hasn’t yet been fully realized.

I think we’ve also strengthened clinical and laboratory research by our ideas about and clues to mechanisms, as well as our getting ideas from them. And we have helped sharpen the tools of clinical investigation while establishing epidemiology as the science of prevention. These are main accomplishments, conceptual, practical, and attitudinal of the discipline of CVD epidemiology, and in turn, of the AHA Council on Epidemiology and Prevention.

R: The next question I have is similar, what needs to be changed in CVD Epidemiology in the future? There is one point when reading the material you have given to me that we should turn away from studies on individual mechanisms.

H: I didn’t mean to say that we turn away from them. I meant to suggest that we do return to our larger public health mission. I don’t know if you as a clinical cardiologist, were as impressed as I that almost all presentations at this year’s San Francisco AHA Epidemiology scientific meeting 2010, had to do with individual medicine, individual prediction, and “the medicalization” of prevention. I felt in a sense that we have become the servant of clinical medicine rather than of the public health. And it’s fine and healthy to make that contribution to the genetics and mechanisms and individual care of CVD. But the program there, representing our national research effort, was exclusively devoted to individual and “personalized medicine,” I thought. I would like to see us resume our broader population thinking, our public health mission, our role as the scientific basis for public health and get back to the environmental and socio-cultural determinants of mass cardiovascular diseases and their epidemics. We must profit, of course, from what we have learned from individual prediction, and of course continue to improve individual prediction with novel risk factors and new and earlier endpoints and so forth. But, I believe that we have virtually abandoned a larger mission to be found at the interface of social culture, environment, disease and health. I’m finding myself more in sympathy with the social medicine people and the social epidemiologists dealing with what’s happening in society, mass behaviors, exposures, the “built environment,” the economy, and legislation encouraging a healthy society. We should be making major research contributions there and I don’t think we are, yet, doing enough at that interface. Or focusing on health as well as on disease as an endpoint. These are areas that I think we need to move back into.

R: Why would you say scientists, particularly clinicians should get involved with the Epi Council?

H. When one becomes an officer in the Council, and on the program committee, for example, one is able to influence the course of the field. For a young person, membership puts one in touch with everybody in the field. It increases opportunities for collaborative research, for developing ideas for research; it increases opportunity for jobs. It puts one “at the center of a universe.”

Of course, at the time that I was there, it was the added excitement of being in a brand new field and we were small and growing. I think that you’ve now got to create your own golden era for the future, but it was certainly wonderful then when we were maybe 100 people and were working out methods and were testing new ideas. But being a member of the Council and serving in various positions of the Council puts you at the center of our little universe and it’s a very fine scientific community.

R: Definitely. The next question is from thinking about one’s research and careers. And should this be promoted in the Epi Council. How could we help careers and getting into activity, finding our way?

H: I guess serving on that Careers Committee, you’re doing more thinking about that than I am. I found the International and Tahoe Seminars absolutely essential to young careers in the worldwide movement. About 3,000 people, maybe more, have been exposed in those seminars over the last 30-40 years. That’s been a wonderful way to involve people in the field. As far as inducements that the Council can offer, young researchers should say “yes” to every opportunity they get to join up and do the jobs assigned them, so they’ll move forward. In how the Council reaches out to those people, I think the seminars are most effective. The American Heart Association Council has sponsored the seminar at Tahoe and the Europeans have individual seminars and there’s the International Seminar still going on.

There also are clinical research programs, clinical research curricula in medical schools from which we in Minnesota have been able to recruit a number of people to cardiovascular epidemiology. Often they recruit themselves; they get clinical research jobs and they want to do better research and so they take our courses in Epi and they get an MPH. I think that might be one area of opportunity for the Council to explore. The Council committee might get a list of the NIH-sponsored clinical research programs and perhaps their counterparts in Europe, although I know there are not as many formal programs in clinical research in Europe, and offer those people opportunities to come to the AHA seminar or to present papers at the annual meeting.

Another approach is to recruit in new cardiovascular areas; peripheral arterial disease, peripheral venous disease, stroke, low risk populations, people working in the various fields of imaging and electrophysiology and interventions, these are areas that could develop a natural interest in acquiring research skills as they can in Epi. I think that people come to us not necessarily with the public health viewpoint that some of us bring, but they come with the need to develop research skills. And we offer those skills in our seminars and in our Masters degrees in epidemiology and statistics. So I think that’s a large area for recruitment and for collaboration. Arrhythmias, interest in heart failure, all these are areas that should be involved in cardiovascular epidemiology skills and training, and participation in Council activities.

R: An odd question, but what is your impression of the number of young researchers and clinicians interested in community medicine and do you think the balance between researchers who are not primarily clinicians and clinicians; is that balance good, or do you think people from other fields and areas should be affected more by CVD Epi?

H. I think we have a good population of young people interested in cardiovascular Epi. We have a wonderful population of young cardiologists and cardiovascular researchers that should be interested in it, and we’ve already talked a good deal about what would make it attractive and how we should approach them. I think you have to create your golden era in some of these new fields that you are working on, arrhythmia, and others. You know what my bias is, that the new golden age would have to do with the public health mission added to our new and heavy involvement with individual medicine, risk, and therapy.

R: If you had a wish for the future, what would your wish be for the Epi Council?

H: I’d like to see young people get more involved with public policy. I would like to reorient our AHA Councils to this larger public mission. I’d also like to see a healthy critique of American Heart Association policy, of European Society of Cardiology (ESC) and INSERM (French) policy, of NIH policy and U.S. joint recommendations for preventive care in hypertension and hypercholesterolemia (now mainly pills, and even the Polypill). I’d like to see an active group in the ESC and in the AHA actually reexamine these issues and work toward getting these policies and recommendations to go more effectively beyond drugs and individual issues, now given only lip service to hygiene, health promotion, and health legislation. I’d like to see questioning of techniques, questioning methods, questioning hypotheses, questioning emphases, and questioning the medically oriented philosophy. In other words, the Council would provide a liberal philosophical leadership, a healthy skepticism, and a greater concern for the common good and the public health as well as for the individual and his physician. I think our young people should help us get out of some of the ruts we now are in, in thinking, and in our research exclusively in personalized medicine. But I rant!

R: Wonderful. We should really think about, maybe how we can change some of those trends.

H: I think we could do that organizationally. I think we could appoint a group on policy, on examining national research policy in cardiovascular diseases. We could really be influential that way.

R: A more personal question. What has a person to gain from being a member of the CVD Epi Council and being the chair of the CVD Epi Council?

H: It really puts you at the center. You’ll know everybody in the field, and it gives you all these opportunities. When you’re on the American Heart Council, when you’re chairman of the Council, you’re at the center of that universe of the prevention community. I also happened to work with Ancel Keys who was a founder of the field. And with Geoffrey Rose, Marti Karvonen, Jerry Stamler, and Richard Remington who were founders of the field. So my position in the Council and in my field gave me a great deal of personal gain in career and professional interests, opportunity for research, but also opportunity to serve.

We are very much in the mode of volunteerism in this country; that’s what the American Heart Assn. is based on, volunteer service to a larger good. It gives you a community outside of your small department or your medical school. A larger community is always a personal gain in satisfaction and ideas, in service, and influence.

R: When you became an elected chair of the CVD Epi Council, what were your expectations?

H: Whatever they were, they were more than fulfilled.

R: It sounded like that when you talked about your time as the CVD Epi Council chair. Is there anything else you would like to say regarding the modern needs of CVD Epi?

H: Well we’ve already talked about where I think it ought to go. I have a new voice now, developing a CVD epidemiology and prevention history website and publications. I don’t know if you’ve been able to look at the website yet. We need to get involved with modern technology to communicate our message and to develop collaborative thinking. I’m encountering these with the History website, and I think there could be international training websites, lectures, blogs, interactive learning, all sorts of things that the field can do to increase communications. You’re obviously outgoing and creative in your undertakings and I wish you and them well.

R: I’m definitely looking forward to this book after I’ve heard so much about it and now on your website I have found very interesting information, particular the interviews with pioneer people from the Epi community and really enjoyed it.

H: Write an essay and I’ll put it on the website, a couple of thousand words. Maybe write on atrial fibrillation?

R: Ok. I thank you very much for your time.

H: I appreciate your calling and I appreciate your paying for the call. We talked an hour!

R: It really was wonderful to talk to you.

By telephone from Germany to Minneapolis, August 21, 2010